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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592101
Report Date: 10/10/2024
Date Signed: 10/10/2024 05:30:04 PM

Document Has Been Signed on 10/10/2024 05:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WALNUT HOME CAREFACILITY NUMBER:
191592101
ADMINISTRATOR/
DIRECTOR:		RABENA, R. & J.FACILITY TYPE:
740
ADDRESS:654 BONNIE CLAIRE DRIVETELEPHONE:
(626) 964-5215
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 6CENSUS: 4DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Richard Rabena, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 10/10/24. LPA met with the administrator, Richard Rabena, and explained the reason for the visit. The facility is licensed to serve 6 residents ages 60 and over, of which 5 may be non-ambulatory and 1 bedridden. Room #7 is approved for the bedridden resident. There is a hospice waiver approved for 2 residents.

LPA inspected the facility using the CARE tool and observed the following.
The single story facility consists of 5 resident bedrooms, 2 Staff rooms, living/dining room, family room, kitchen, 2 bathrooms, and the attached garage. Staff room #1 has a private bathroom. The backyard has a shaded area for resident use. The hot water temperature was measured between the required range of 105-120 degrees F. There are no swimming pool or bodies of water on the premises. The facility has a carbon monoxide detector located in the hallway. Sufficient food supplies of 2 day perishable and a week of non-perishable are observed. Facility has sufficient space to provide indoor and outdoor activities to residents. Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are currently no residents with prohibited or restricted health conditions. No residents are using oxygen equipment. Medications are centrally stored and locked in the hallway cabinet.
LPA reviewed 4 resident files and medications. Resident #4 did not have the annual medical assessment on file. Medications are being administered as prescribed. LPA reviewed 3 personnel files. The files have the required forms and health assessment with TB test results. Annual training are being provided to staff. Administrator's certificate expires on 7/27/25. The Emergency Disaster Plan is reviewed annually and has the emergency procedures indicated.

A deficiency is issued on the LIC809D form. An exit interview was held and a copy of this report along with appeal rights was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2024 05:30 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 10/10/2024 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WALNUT HOME CARE
FACILITY NUMBER: 191592101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The licensee shall ensure residents with dementia obtain an annual medical assessment and appraisal done at least annually. Licensee will submit the updated medical assessment and reappraisal plan to LPA by 10/31/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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